Exam 4 EAQs
A client seeks help for dealing with incontinence. A nursing intervention is to teach Kegel exercises. Which type of incontinence is the client most likely experiencing? A. Reflex incontinence B. Stress incontinence C. Overflow incontinence D. Functional incontinence
B. Stress incontinence Stress incontinence is the involuntary loss of urine during coughing, laughing, or sneezing. In women, this is often seen after having children. Kegel exercises increase the perineal muscle tone, helping to control involuntary voiding. Overflow incontinence is caused by overdistention of the bladder, and exercises will not help. Reflex incontinence is preceded by abnormal detrusor contractions from neurologic abnormalities. Functional incontinence is associated with environmental or cognitive factors due to which the client is unable to get to the toilet or does not have the necessary cognitive abilities to use the toilet.
An older adult has undergone chemotherapy. Which intervention would be beneficial for the client in preventing the risk of a potentially contagious common viral infection? A. Administering famciclovir B. Administering gabapentin C. Administering the zoster vaccine D. Administering vaccines for HSV1 & HSV2
C. Administering the zoster vaccine Herpes zoster or shingles is the most common viral infection that is potentially contagious to anyone who has not had varicella or who is immunosuppressed such as clients on chemotherapy. Incidence increases with age mainly for adults 50 years old or older. Administering the zoster vaccine helps in preventing the risk of shingles. Famciclovir is an antiviral drug that helps in reducing the symptoms of the infection. Gabapentin is prescribed to clients suffering from neuralgia caused by shingles. Vaccines for HSV-1 and HSV-2 are not available.
A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis? A. Rectal examination B. Serum phosphatase level C. Biopsy of prostatic tissue D. Massage of prostatic fluid
C. Biopsy of prostatic tissue A definitive diagnosis of the cellular changes associated with benign prostatic hyperplasia (BPH) is made by biopsy, with subsequent microscopic evaluation. Palpation of the prostate gland through rectal examination is not a definitive diagnosis; this only reveals size and configuration of the prostate. The serum phosphatase level will provide information for prostatic cancer; a definitive diagnosis cannot be made with this test for BPH. A sample of prostatic fluid helps to diagnosis prostatitis.
A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? A. Large area of petechiae B. Red birthmark that has recently become lighter in color C. Brown or black mole with red, white, or blue areas D. Patchy loss of skin pigmentation
C. Brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? A. Sunken eyes B. Dry, flaky skin C. Change in mental status D. Decreased bowel sounds
C. Change in mental status Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client.
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? A. Urge incontinence B. Stress incontinence C. Overflow incontinence D. Functional incontinence
C. Overflow incontinence Overflow incontinence describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities).
Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate? A."Your urine will be pink and free of clots" B. "You will have an abdominal incision and a dressing" C. "There will be an incision between your scrotum and rectum" D. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place"
D. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place" The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for hemostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP, the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent. An incision between the scrotum and rectum is associated with a perineal prostatectomy, not a TURP.
A client who had a history of chicken pox arrived at the hospital complaining of itching and deep pain on the skin. Which assessment finding made by the nurse helps to confirm the diagnosis? A. Appearance of red, moist, irritated skin B. Appearance of red-colored, raised rash with pustules C. Appearance of sore-looking raised bumps on the skin D. Appearance of multiple lesions in a segmental distribution on the skin
D. Appearance of multiple lesions in a segmental distribution on the skin The client who had a history of chicken pox may have a chance of getting herpes zoster. Multiple lesions in a segmental distribution on the skin may be a viral infection such as herpes zoster. A red, moist, irritated appearance on the skin is due to a fungal infection like Candida albicans. Red-colored raised bump appearances on the skin are due to bacterial infections such as folliculitis. Sore-looking raised bumps on the skin are due to bacterial infections like furuncles.
The nurse is developing a postprocedure plan of care for a client with a continuous bladder irrigation after a transurethral vaporization of the prostate. What should the nurse include in the plan? A. Measure the output hourly B. Monitor the specific gravity of the urine C. Irrigate the catheter with saline TID D. Exclude the amount of irrigant instilled from the output
D. Exclude the amount of irrigant instilled from the output The amount of irrigant instilled into the bladder must be deducted from the total output to determine the amount of urine produced. The client will have an indwelling catheter, and hourly measurements are not possible because the irrigant is mixing with the urine. Abnormal specific gravity values are not associated with this procedure and would be inaccurate because the irrigant is mixing with the urine. Because the bladder is being irrigated continuously no additional irrigations are needed.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? A. Primary B. Secondary C. Superinfection D. Nosocomial
D. Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.
The nurse finds that a client has dysuria, hesitancy, urinary urgency, and leaking. The laboratory reports of the client reveal serum PSA levels of 5 ng/mL and elevated prostatic acid phosphatase (PAP) levels. Which disease condition does the nurse suspect? A. Orchitis B. Hydrocele C. Prostatitis D. Prostate cancer
D. Prostate cancer Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling. PSA is a blood test used to confirm prostate cancer. An elevated level of prostatic isoenzyme of serum acid phosphatase (PAP) is another indicator of prostate cancer. The normal range of PSA levels is 0-4 ng/mL. Therefore, the client has elevated PSA levels. Acute inflammation of the testis indicates orchitis, which is characterized by painful, tender, and swollen testis. A hydrocele is nontender, scrotal swelling caused by an accumulation of serous fluid in the scrotum. PSA levels are not elevated with a hydrocele. Prostatitis is a condition that involves inflammation of the prostate gland and is characterized by fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine. Increased PSA levels also indicate prostatitis, but the symptoms such as hesitancy and dribbling, and elevated levels of PAP are not associated with prostatitis.
A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion? A. Exposure to radiation B. Location of the lesion C. Self-treatment of lesions D. Contact with soil contaminants
A. Exposure to radiation The major cause of skin cancer is exposure to the sun's ultraviolet light, a form of radiation. Farmers are susceptible to this type of cancer. The location of the lesion is not a causative factor of skin cancer. Self-treatment of a lesion is not a causative factor of skin cancer. Although environmental pollutants may have some bearing, they are not considered the major cause of skin cancer.
On the first day after a mastectomy, a nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. The client asks why she has to do these exercises. What is the best response by the nurse? A. "They preserve muscle tone" B. "They prevent joint contratures: C. "They help us to assess the extent of the lymphedema" D. "They will help to stimulate peripheral circulation"
D. "They will help to stimulate peripheral circulation" These exercises require muscle contractions that put pressure on blood vessels; muscle contraction promotes circulation, increasing tissue oxygen. Muscle atrophy is not a common complication after mastectomy. Contractures are a rare complication after a mastectomy. Lymphedema is assessed by measuring the circumference of the extremity, not by having the client exercise.
During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, what can the nurse do to offset nutritional deficiencies? A. Provide oral supplements B. Offer the client's favorite foods C. Restrict intake from dairy products D. Encourage the client to drink low-protein shakes
A. Provide oral supplements The client with cancer may experience protein and calorie malnutrition characterized by fat and muscle depletion. Soft, nonirritating high-protein and high-calorie foods should be eaten throughout the day. Foods suggested for increasing the protein intake and high-calorie foods that provide energy and minimize weight loss are recommended. Teach the client to avoid extremes of temperature of food, spicy or rough foods, and other irritants. Encourage nutritional supplements like Ensure as an adjunct to meals and fluid intake. Teach the client to use nutritional supplements in place of milk when cooking or baking. Foods to which nutritional supplements can be easily added include scrambled eggs, pudding, custard, mashed potatoes, cereal, and cream sauces. Packages of instant breakfast can be used as indicated or sprinkled on cereals, desserts, and casseroles. Families are an integral part of the healthcare team. As symptom severity increases, the family's role in helping the client eat becomes increasingly critical. If the malnutrition cannot be treated with dietary intake, it may be necessary to use enteral or parenteral nutrition. Favorite foods are not offered during chemotherapy because the client's sense of taste has changed. Dairy products are a necessary part of a balanced diet and do not affect chemotherapy. High-protein shakes are used to encourage healing and protein intake.
The nurse is teaching a nursing student about the care given to a client before a prostate specific antigen (PSA) test. Which statement made by the nursing student indicates a need for further teaching? A. "Clients should not take saw palmetto for 2 weeks before the test" B. "I will ask the client to be NPO before the test" C. "I need to assess the venipuncture site for hematoma and bleeding" D."PSA is produced by cancerous and noncancerous prostate tissue"
B. "I will ask the client to be NPO before the test" It is not necessary to ask the client to have nothing by mouth (NPO) before a prostate specific antigen (PSA) test, so this would require further teaching. PSA is a protein that is produced by both cancerous and noncancerous prostate tissue. Saw palmetto is an herb used for sexual potency that can produce a false negative PSA result, so the nurse should instruct the client to discontinue taking it for 1 to 2 weeks before PSA testing. The PSA test is a blood test requiring venipuncture, so the nurse should observe the puncture site for bleeding and hematoma.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? A. Stage I B. Stage II C. Stage III D. Unstageable
D. Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? A. Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence B. Place a waterproof pad under the client to prevent incontinence and soiling the linens C. Check the client's buttocks at least q2H; clean the client immediately after discovering incontinence D. Offer toileting to the client q2H to prevent incontinence
C. Check the client's buttocks at least q2H; clean the client immediately after discovering incontinence Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instructing the client to call for help with elimination needs is not helpful, because the client is confused and unable to use the call bell. Placing a waterproof pad beneath the client helps to prevent soiling of the bed but does not keep feces away from the client's skin and therefore does not prevent skin breakdown. Toileting the client every 2 hours to prevent incontinence is not helpful, because the client is confused and unable to follow commands and has no control over elimination needs.
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? SATA. A. Assessment of skin turgor B. Documentation of VS C. Assessment of intake & output D. Administration of antiemetic drugs E. Replacement of fluid and electrolytes
A, D, E When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.
A nurse is reviewing a postmenopausal client's history, which reveals that the client previously received hormonal therapy (HT) as treatment for osteoporosis. The nurse recognizes that HT increases the risk of which condition? A. Breast cancer B. Rapid weight loss C. Accelerated bone loss D. Vaginal tissue atrophy
A. Breast cancer There is a relationship between HT that combines estrogen and progesterone compounds and an increased incidence of invasive breast cancer. One side effect of HT is weight gain with ankle and foot edema. Bone loss is slowed with HT. Vaginal tissue maintains turgor and lubrication with HT.
The primary healthcare provider of a woman who had a mastectomy has arranged for a mastectomy peer support visit. What does the nurse identify as the primary reason for the referral? A. To learn arm exercises B. To prevent social isolation C. To meet her physical needs D. To view her surgical incision
B. To prevent social isolation A mastectomy peer support visit helps the client meet her need to remain within her social milieu and informs her about available community resources. Teaching arm exercises, meeting the client's physical needs, and viewing her surgical incision are all responsibilities of health care professionals.
A client receiving chemotherapy for cancer develops sores in the mouth and asks the nurse why this happened. What is the nurse's best response? A. "The sores occur because of the direct irritating effects of the drug" B. "These tissues are poorly nourished because you have a decreased appetite" C. "The frequently diving cells of the GI tract are damaged by the drug" D. "This side effect occurs because it targets the cells of the GI system"
C. "The frequently diving cells of the GI tract are damaged by the drug" Many chemotherapeutic agents function by interfering with DNA replication associated with cellular reproduction (mitosis). Frequent cellular mitosis of the stratified squamous epithelium of the mouth and anus results in these areas being powerfully affected by the drugs. The response "The sores occur because of the direct irritating effects of the drug" is inaccurate; most agents are administered parenterally. A decreased appetite (anorexia) does not cause stomatitis. Chemotherapeutic agents affect most rapidly proliferating cells, which include not only the cells of the gastrointestinal epithelium but also those of the bone marrow and hair follicles.
A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. What explanation will the nurse provide? A. Steroid hormones have a depressant effect on the spleen and bone marrow B. Lymph node activity is depressed by radiation therapy used before chemotherapy C. Noncancerous cells are also susceptible to the effects of chemotherapeutic drugs D. Dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration
C. Noncancerous cells are also susceptible to the effects of chemotherapeutic drugs Chemotherapy destroys erythrocytes, white blood cells, and platelets indiscriminately along with the neoplastic cells because these are all rapidly dividing cells that are vulnerable to the effects of chemotherapy. Stating that steroid hormones have a depressant effect on the spleen and bone marrow is not a true description of the side effects of steroids. Depressed lymph node activity as a result of radiation therapy used before chemotherapy is not the cause for fewer erythrocytes, white blood cells, and platelets. Although it is true that dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration, this does not explain pancytopenia.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? A. Pouring warm water over the perineum B. Ensuring the patency of the catheter C. Removing the catheter within 24 hours D. Cleaning the catheter insertion site
C. Removing the catheter within 24 hours Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
What is the most important information for the nurse to teach to a client who has had a total simple mastectomy before she leaves the hospital? A. Why a breast prothesis is necessary B. Which of the more strenuous activities to curtail C. What household tasks that require stretching to avoid D. Why self-examination of the remaining breast is important
D. Why self-examination of the remaining breast is important A person who has cancer of one breast is at risk for the development of cancer in the other breast. A breast prosthesis is not used until healing has occurred. Most clients are able to resume full activity as strength returns. Stretching activities are considered helpful in regaining full movement.
A client is scheduled for a modified radical mastectomy. What nursing intervention is most important in the client's preoperative plan of care? A. Allowing her to express her feelings about the surgery B. Encouraging range-of-motion exercises of the arms C. Increasing her knowledge about post-op expectations D. Arranging for a visit by a woman who has had a mastectomy
A. Allowing her to express her feelings about the surgery The freedom to vent feelings about the loss of a body part and its meaning to the client influences the client's willingness to participate in the postoperative regimen, consequently affecting healing and rehabilitation. Encouraging range-of-motion exercise of the upper extremities is not the initial preoperative focus. First the client's level of anxiety must be identified; teaching is not effective if the client is even moderately anxious. Arranging for a visit by a woman who has had a mastectomy is not an initial action; it is usually arranged after surgery.
A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain 1 week later. What does the nurse identify as the cause of the posttherapeutic neuralgia? A. Damage to the nerves B. Untreated major depression C. Scarring in the area of the rash D. Continued presence of the skin rash
A. Damage to the nerves After the original infection has healed, the virus either remains quiescent or it may return. Posttherapeutic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; the neuralgia may last for months. Untreated major depression and scarring in the area of the rash are unrelated to posttherapeutic neuralgia. The rash does not cause posttherapeutic neuralgia.
A 37-year-old client with a nontender palpable breast mass has an inconclusive mammogram. She is undergoing further diagnostic tests to determine whether the mass is malignant. What information should the nurse take into consideration before planning health teaching for this client? A. Squamous cell carcinomas are neoplasms arising from glandular tissues B. Results of a biopsy are necessary before a specific form of therapy is selected C. Mammographies should be repeated to confirm the presence of malignancies D. Waiting for several weeks before receiving confirmation of cancer is helpful to the client
B. Results of a biopsy are necessary before a specific form of therapy is selected The therapy selected depends on whether there is a malignancy and, if so, the type of cancer cells, the extent of nodal involvement, and the presence and extent of metastasis. Adenocarcinomas, not squamous cell carcinomas, arise from glandular tissue; squamous cell carcinomas arise from epithelial tissue. Only a biopsy will confirm the diagnosis of a malignancy. Waiting several weeks for a diagnosis is not advisable; an extended waiting period increases the client's stress and anxiety.
A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center for an appointment for a mammogram. What guidance should the nurse provide the client in preparation for the test? A. Do not eat for 6 hours before the test B. The room will be darkened throughout the procedure C. The first mammogram is usually performed at 50 years of age D. During the procedure, each breast will be compressed firmly between two plates
D. During the procedure, each breast will be compressed firmly between two plates Compression of the breast flattens mammary tissue and maximizes penetration of the breast by x-rays; this is especially important for the dense breast tissue of adolescents, young nulliparous women, and women with large breasts. Fasting before the test is not necessary. The room is usually darkened for sonography, not mammography. The American Cancer Society recommends that women at risk for breast cancer (the client's sister had breast cancer) should have routine mammography, regardless of age or relationship to menopause. It is recommended that a woman have her first mammogram by age 40 to establish a baseline for future annual mammograms.
The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? SATA. A. "I will elevate the client's HOB to no more than 30º" B. "I will ensure that the client is turned and repositioned at least q2H" C. "I will advise the client to apply talc directly to the perineum" D. "I will ensure that the client's fluid intake is 2000 to 3000 mL/day" E. "I will teach the client to refrain from eating a high-protein and calorie diet"
A, B, D The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure ulcers. Turning and repositioning the client frequently improves circulation, and redistributes body weight over bony prominences, both of which reduce the risk of pressure ulcer formation. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps to nourish the skin. The client should not apply talc directly to the perineum. The client should take in an adequate amount of protein and calories in the diet.
An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? SATA. A. Providing meticulous skin care B. Reducing shear forces and friction C. Providing beverages and snacks frequently D. Using a support surface base all the time E. Avoiding pressure with proper positioning
A, B, E Providing an older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure ulcers. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.
Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair
A. Incontinence and inability to move independently Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.
What are the clinical manifestations of actinic keratosis in a client? SATA. A. Firm, nodular lesions B. Small papules with dry skin C. Wrinkled, weather-beaten skin D. Pearly papules with a central crater E. Irregularly shaped, pigmented papules
B, C Small papules with dry skin and wrinkled, weather-beaten skin are clinical manifestations of actinic keratosis. Firm, nodular lesions are clinical manifestations of squamous cell carcinoma. Pearly papules with a central crater are the clinical manifestations of basal cell carcinoma. Irregularly shaped, pigmented papules are the clinical manifestations of melanoma.
An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? SATA. A. Provide nutritional support B. Provide voiding opportunities C. Avoid indwelling catheterization D. Provide beverages and snacks frequently E. Promote measures to prevent skin breakdown
B, C, E An older adult should be provided voiding opportunities to minimize urinary incontinence. Indwelling catheterization should be avoided because this action increases the risk of infection and may cause discomfort. Measures to prevent skin breakdown should be taken because the client may develop skin problems due to incontinence. Nutritional support and frequent beverages and snacks should be provided to a client with malnutrition.
A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? A. Insert a urinary retention catheter B. Institute measures to prevent constipation C. Encourage an increase in the intake of caffeine D. Suggest that a carbonated beverage be ingested daily
B. Institute measures to prevent constipation A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence. Urinary retention catheters should not be used to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence. Caffeine acts as a diuretic and is a urinary bladder irritant; both promote urinary incontinence. Carbonated beverages irritate the urinary bladder, which promotes urinary incontinence.
For which clinical manifestation should the nurse assess a client with melanoma? A. Firm, nodular lesion with a crusty top B. Irregularly shaped, pigmented papule C. Small papule with dry, rough, brown scale D. Pearly papule with a central crater and waxy border
B. Irregularly shaped, pigmented papule Melanoma is an irregularly shaped, pigmented papule or plaque. Basal cell carcinoma is a pearly papule with a central crater and rolled, waxy borders. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or with a central area of ulceration. Actinic keratosis is a small macule or papule with dry, rough, adherent yellow or brown scale.
A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy dry skin? What is the best response by the nurse? A. Wear plenty of warm clothes to keep moisture in the skin B. Use a moisturizer on the skin daily to reduce itching C. Take hot tub baths only twice per week to reduce the drying of the skin D. Expose the skin to air to help reduce the sensation of itching
B. Use a moisturizer on the skin daily to reduce itching Lubricating the skin with a moisturizer effectively relieves dryness and thus the pruritus (itching). Wearing warm clothing will not lubricate the skin or relieve pruritus. Warm or cool, not hot, tub baths will reduce itching. Exposing the skin to the air causes further drying and will not relieve pruritus.
What are the priority care issues during chemotherapy? SATA. A. Resources available for the nurse B. Handling the chemotherapy drugs C. Managing the client's complications D. Protecting the client from side effects E. Treatment areas in which to serve the client
C, D Managing the client's complications and protecting the client from side effects are the high-priority care issues to be considered during chemotherapy. Handling resources available for the nurse, the chemotherapy drugs, and the treatment areas in which to serve clients can be managed by effective planning of the healthcare team.
A client has a basal cell carcinoma that is scheduled to be removed. The client expresses concerns that the cancer has metastasized. Which is the best response by the nurse? A. "You are a low surgical risk" B. "I can understand how you must feel" C. "Basal cell tumors usually do not spread" D. "The PCP probably caught it just in time"
C. "Basal cell tumors usually do not spread" Basal cell tumors usually do not spread, so the statement is accurate. The response "You are a low surgical risk" does not speak to the client's concern. The response "I can understand how you must feel" may provide reassurance but does not permit further exploration of concern. The response "The primary healthcare provider probably caught it just in time" reinforces the client's fears instead of pointing out reality.
